Event Notification Report for April 09, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/08/2003 - 04/09/2003
EVENT NUMBERS
39747397443974541975
Hospital
Event Number: 39747
Rep Org: OJOS HOSPITAL
Licensee: OJOS HOSPITAL
Region: 2
City: SAN JUAN State: PR
County:
License #:
Agreement: N
Docket:
NRC Notified By: DAVID RHOE
HQ OPS Officer: STEVE SANDIN
Licensee: OJOS HOSPITAL
Region: 2
City: SAN JUAN State: PR
County:
License #:
Agreement: N
Docket:
NRC Notified By: DAVID RHOE
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/10/2003
Notification Time: 14:22 [ET]
Event Date: 04/09/2003
Event Time: 00:00 [EDT]
Last Update Date: 04/10/2003
Notification Time: 14:22 [ET]
Event Date: 04/09/2003
Event Time: 00:00 [EDT]
Last Update Date: 04/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE 35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE 35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
BRIAN BONSER (R2)
DOUG BROADDUS (NMSS)
BRIAN BONSER (R2)
DOUG BROADDUS (NMSS)
MEDICAL EVENT INVOLVING SR-90 EYE APPLICATOR EXCEEDING THE PRESCRIBED DOSE BY 32%
The Ojos Hospital located in San Juan, PR sent a New England Nuclear Model NB-1, S/N 0433, to the University of WI for calibration in October of 2002. The unit was returned with the calibration source, however, technicians at the hospital failed incorporate the results into the respective documents at the hospital. This resulted in approximately 36 patients receiving a dose 32% higher than the prescribed dose. Typical doses administered during treatment are 1000, 1500 or 2000 rads. In the case of a 2000 rad prescribed dose, the actual dose delivered is 2646 rads. The consultant who performs semi-annual leak tests discovered the discrepancy and notified hospital management who ceased at treatment with this device on 4/9/03. The affected patents have not been informed.
The Ojos Hospital located in San Juan, PR sent a New England Nuclear Model NB-1, S/N 0433, to the University of WI for calibration in October of 2002. The unit was returned with the calibration source, however, technicians at the hospital failed incorporate the results into the respective documents at the hospital. This resulted in approximately 36 patients receiving a dose 32% higher than the prescribed dose. Typical doses administered during treatment are 1000, 1500 or 2000 rads. In the case of a 2000 rad prescribed dose, the actual dose delivered is 2646 rads. The consultant who performs semi-annual leak tests discovered the discrepancy and notified hospital management who ceased at treatment with this device on 4/9/03. The affected patents have not been informed.
Power Reactor
Event Number: 39744
Facility: SALEM
Region: 1 State: NJ
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEVIN MORGAN
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: NJ
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEVIN MORGAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/09/2003
Notification Time: 13:14 [ET]
Event Date: 04/09/2003
Event Time: 12:00 [EDT]
Last Update Date: 04/09/2003
Notification Time: 13:14 [ET]
Event Date: 04/09/2003
Event Time: 12:00 [EDT]
Last Update Date: 04/09/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES TRAPP (R1)
JAMES TRAPP (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION DUE TO LETHAL SHORT- NOSE STURGEON TAKE
The following information was received from the Licensee via facsimile:
"A sturgeon was recovered from the Circulating Water intake during normal trash raking. Environmental Licensing was notified to determine the species of sturgeon. It was determined to be a shortnose sturgeon (Endangered). Initially the sturgeon was alive and injured. Following recovery, the sturgeon died. The National Fisheries and the New Jersey D.E.P. [Department of Environmental Protection] was notified."
Additionally, the Licensee notified Lower Alloway Township.
The Licensee has notified the NRC Resident Inspector.
The following information was received from the Licensee via facsimile:
"A sturgeon was recovered from the Circulating Water intake during normal trash raking. Environmental Licensing was notified to determine the species of sturgeon. It was determined to be a shortnose sturgeon (Endangered). Initially the sturgeon was alive and injured. Following recovery, the sturgeon died. The National Fisheries and the New Jersey D.E.P. [Department of Environmental Protection] was notified."
Additionally, the Licensee notified Lower Alloway Township.
The Licensee has notified the NRC Resident Inspector.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 39745
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [] [] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JAMES BLAZEK
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: AZ
Unit: [] [] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JAMES BLAZEK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/09/2003
Notification Time: 23:42 [ET]
Event Date: 04/09/2003
Event Time: 19:43 [MST]
Last Update Date: 05/02/2003
Notification Time: 23:42 [ET]
Event Date: 04/09/2003
Event Time: 19:43 [MST]
Last Update Date: 05/02/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
DAVE LOVELESS (R4)
DAVE LOVELESS (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Refueling | 0 | Refueling |
UNATTENDED SECURITY HANDGUN FOUND IN THE PROTECTED AREA
Immediate compensatory measures taken upon discovery.
The Licensee has notified the NRC Resident Inspector.
*** RETRACTION FROM D. MARKS TO A. COSTA AT 1858 ON 5/2/03 ***
Upon further review of 10 CFR 73, Appendix G, Paragraph 1(a)(3), the Licensee is retracting this event notification. Contact the NRC Headquarters Operations Officer for additional details.
The Licensee notified the NRC resident inspector. Notified the R4DO (Pick).
Immediate compensatory measures taken upon discovery.
The Licensee has notified the NRC Resident Inspector.
*** RETRACTION FROM D. MARKS TO A. COSTA AT 1858 ON 5/2/03 ***
Upon further review of 10 CFR 73, Appendix G, Paragraph 1(a)(3), the Licensee is retracting this event notification. Contact the NRC Headquarters Operations Officer for additional details.
The Licensee notified the NRC resident inspector. Notified the R4DO (Pick).
Hospital
Event Number: 41975
Rep Org: WASHINGTON HOSPITAL CENTER
Licensee: WASHINGTON HOSPITAL CENTER
Region: 1
City: WASHINGTON DC State: DC
County:
License #: 08-03604-05
Agreement: N
Docket:
NRC Notified By: A. EREMIA
HQ OPS Officer: JOHN MacKINNON
Licensee: WASHINGTON HOSPITAL CENTER
Region: 1
City: WASHINGTON DC State: DC
County:
License #: 08-03604-05
Agreement: N
Docket:
NRC Notified By: A. EREMIA
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/09/2005
Notification Time: 11:43 [ET]
Event Date: 04/09/2003
Event Time: 00:00 [EDT]
Last Update Date: 09/09/2005
Notification Time: 11:43 [ET]
Event Date: 04/09/2003
Event Time: 00:00 [EDT]
Last Update Date: 09/09/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
FRANK COSTELLO (R1)
M. BURGESS (NMSS)
FRANK COSTELLO (R1)
M. BURGESS (NMSS)
PATIENT COUGH CAUSED RADIATION DOSE TO BE ADMINISTERED NO MORE THAN 6 MILLIMETERS FROM THE CORRECT SITE.
A patient was having a hearing loss due to pressure (tumor inside the brain). The patient was being treated using a gamma knife. Toward the end of the patient's final treatment, toward the end of the 11 stage of the treatment plan, the patient coughed. The cough caused a pin used to stabilize the patient's skull to become dislodged (shifted). This resulted in the patient being administered a dose not directly to the tumor (dose administered no more than 6 millimeters from the correct area). No harm was caused to the patient. All physicians involved in the case were notified. The licensee has been discussing this event for the last couple of years and they were asked to report this event to the NRC Headquarters Operation Officer.
A patient was having a hearing loss due to pressure (tumor inside the brain). The patient was being treated using a gamma knife. Toward the end of the patient's final treatment, toward the end of the 11 stage of the treatment plan, the patient coughed. The cough caused a pin used to stabilize the patient's skull to become dislodged (shifted). This resulted in the patient being administered a dose not directly to the tumor (dose administered no more than 6 millimeters from the correct area). No harm was caused to the patient. All physicians involved in the case were notified. The licensee has been discussing this event for the last couple of years and they were asked to report this event to the NRC Headquarters Operation Officer.